1. Vaccines, Apparent Life-Threatening Events,
Barlow’s Disease, and Questions about
“Shaken Baby Syndrome”
6
Michael D. Innis, MBBS Geddes et al. have hypothesized that in the immature brain,
hypoxia alone is sufficient to activate the pathophysiologic cascade
that culminates in dural hemorrhage. Is it possible that ALTE, when
ABSTRACT
associated with anoxia and cyanosis, could cause subdural
Apparent Life-Threatening Events (ALTEs), as defined by the hemorrhage in conformity with the Geddes hypothesis?
National Institutes of Health, encompass all the findings hitherto Moreover, the clinical picture of Barlow’s disease, infantile
attributed to “Shaken Baby Syndrome” (SBS), and may follow vitamin C deficiency, resembles that of “battered baby”7 or child
routine vaccination. Vaccines may also induce vitamin C deficiency abuse,8 as it may also present with multiple hemorrhages and fractures.
(Barlow’s disease), especially in formula-fed infants or infants
whose mothers smoke. This could account for some of the changes Case 1
seen in these infants, including hemorrhages, bruises, and
fractures. Vitamin C deficiency should be excluded in patients A male infant was born to a 20-year-old mother after a 41-week
suspected to have SBS. gestation by normal vaginal delivery. His Apgar scores were 8 at
one minute and 9 at five minutes. Injections of vitamin K 1 mg (IM)
Definitions and hepatitis B vaccine (Hep B) were given. During pregnancy the
mother had a urinary tract infection and iron-deficiency anemia and
“Shaken baby syndrome” (SBS) is a collection of findings, not had been treated with an antibiotic and ferrous sulfate. The infant
all of which may be present in any individual infant diagnosed to was breastfed for two months and then fed formula. The mother
have the condition. Findings include intracranial hemorrhage, smoked about 10 cigarettes per day.
retinal hemorrhage, and fractures of the ribs and at the ends of the At the infant’s routine check at age 2 months, his navel had still
long bones. Impact trauma may produce additional injuries such as
not healed, and some bright red discharge was noted.
bruises, lacerations, or other fractures.1 Immunizations consisting of diphtheria, tetanus, and acellular
The National Institutes of Health, at its 1986 Health Consensus
pertussis (DTaP), Hemophilus influenzae B (Hib), and Hep B
Development Conference on Infantile Apnea and Home
vaccines were given. These were repeated two months later.
Monitoring, defined “Apparent Life-Threatening Event” (ALTE)
On the night after the second set of immunizations, the mother
as an episode that is frightening to the observer and is characterized
said the infant was “fussy,” and she gave him Tylenol. The
by some combination of apnea (central or occasionally
following day the baby’s father gave him a bath and put him on the
obstructive), color change (usually cyanotic or pallid but
bed while he attended to some other matter for about two minutes.
occasionally erythematous or plethoric), marked change in muscle
When he returned, he found that the infant was limp, unresponsive,
tone (usually marked limpness), and choking or gagging. In some
cases, the observer fears that the infant has died. ALTE is not so and not breathing. Shortly thereafter the infant became blue.
much a specific diagnosis as a description of an event. On arrival at the nearest hospital, the infant was found to be
pulseless. He was intubated and mechanically ventilated, and his
Overview pulse was restored. Examination revealed evidence of an
intracranial bleed and bilateral retinal hemorrhages. The magnetic
SBS is often suspected in infants who present with unexplained resonance imaging (MRI) report stated: “There is abnormal
bruising, subdural hemorrhages, and retinal hemorrhages. Manual restricted diffusion and decreased apparent diffusion coefficient in
shaking with whiplash-induced intracranial and intraocular bleeds the entire territory of the bilateral anterior and posterior cerebral
is thought to be the most likely cause of these injuries.2 6- However, arteries and partial left greater than the right middle cerebral
on questioning, most parents and caregivers vehemently deny arteries. These findings are consistent with acute ischemic
having shaken or harmed the baby. Could the symptoms classically infarction. Minimal extra-axial parafalcine interhemispheric
attributed to SBS actually have another cause? hyperintense signal on T1 and diffusion weighted images is likely a
In the case reports that follow, further analysis of the clinical, small [acute] subdural hemorrhage. Effacement of the sulci in the
laboratory, and postmortem features in infants diagnosed with SBS areas of infarction is consistent with edema. No evidence to suggest
suggests the possibility of an alternate explanation for their posterior fossa infarct is demonstrated.”
subdural hemorrhages, retinal hemorrhages, and bony lesions or In addition, another report noted “subdural hemorrhages
bruises. In each of these instances, an ALTE occurred. All the [presumed to be acute] extending from the posterior fossa, through
caregivers involved in these cases have strongly and repeatedly the foramen magnum, and along the dorsal cord to the inferior end-
rejected the notion of nonaccidental injury or SBS. plate of C3. No cord compression or deformity.”
Journal of American Physicians and Surgeons Volume 11 Number 1 Spring 2006 17

2. Multiple computerized axial tomographic (CAT) sections of the Radiologic and postmortem examinations showed that the
head were obtained without contrast and showed “findings anterior ends of the third through tenth ribs were “broadened”
consistent with sub-arachnoid hemorrhage as well as cerebral bilaterally. This is consistent with the typical “scorbutic rosary”
edema associated with anoxia.” alluded to in Nelson’s Textbook of Pediatrics in which, referring to
A skeletal survey showed “findings consistent with a infantile scurvy, it is stated: “A ‘rosary’ at the costochondral
10
nondisplaced fracture of the distal left tibia,” and two weeks later junctions and depression of the sternum are other typical features.”
the report stated, “the previously noted nondisplaced left distal Other relevant laboratory results were as follows: Factor VIII,
tibial fracture is not well seen.” The possibility of temporary brittle 221 IU/dL (normal range 50–125); von Willebrand factor antigen,
bone disease as described by Paterson et al., who attributed it to a 253 IU/dL (50–246); fibrinogen, 4.0 g/L (1.7–4.0); alkaline
temporary deficiency of an enzyme in the post-transitional phosphatase, 321 U/L (65–265); alanine transaminase, 59 U/L
9
processing of collagen, was apparently not considered. (5–45); lactate, 6.6 mmol/L (1.1–2.2); calcium, 2.32 mmol/L
Blood studies showed a prothrombin time of 17.9 sec (normal (2.37–2.74); albumin, 28 g/L (35–55); lysine, 55 µmol/L
range, 8.2–14.1); partial thromboplastin time, 35.5 sec (28.0–50.0); (100–300); hemoglobin, 9.0 g/L (10–13.5); lymphocytes, 2.80
9 9
aspartate aminotransferase, 97 U/L (20–60); glycine, 131 µmol/L x10 /L (3–13.5); and eosinophils, 0.01 x 10 /L (0.1-0.3). In addition
(224–514); lysine, 66 µmol/L (114–269); hemoglobin, 11.0 g/dL (10- to lysine, the levels of six other essential amino acids were reduced.
9
13.5); platelets, 382 x 10 /L (150–450); pH, 7.26 (7.35-7.45); Levels of glutamine and two other nonessential amino acids were
bicarbonate, 18.2 mmol/L (21–29); and glucose, 188 mg/dL (60–80). also reduced.
The recorded diagnoses were “non-accidental injury” and Autopsy revealed subdural and subarachnoid hemorrhages,
“shaken baby syndrome.” The infant survived, but was cerebral edema, and widespread acute ischemic changes.
developmentally delayed and required a gastrostomy. There was general agreement among the pediatricians,
radiologists, and pathologists that the varying age of the lesions
Case 2 indicated repeated episodes of violent abuse such as shaking, and
that death was caused by nonaccidental injury. Yet there had been
A female infant was born at term weighing 2.9 kg. The mother no evidence of injury or other reason to suspect abuse at the time of
had almost daily vomiting throughout the pregnancy and weighed hospitalization, or in the many visits to the doctor’s office. The
origin of the “fractures” remains undetermined; however, given the
less after delivery than she did before she became pregnant.
compromised nutritional status of the baby in utero, fractures could
Because of the persistent vomiting, she was unable to consume the
be caused by temporary brittle bone disease.
vitamin and iron supplements she was advised to take. She also
smoked during her pregnancy. The infant was given an IM injection
Discussion
of 1 mg vitamin K at birth. She was formula fed.
At about three weeks of age the infant suddenly awakened from
The current concept of SBS includes intracranial bleeding,
her sleep, screaming. The mother interpreted the scream as a cry of
usually in the form of a subdural hematoma, which may be acute or
pain rather than hunger. The infant vomited, and then settled after a
chronic; parenchymal injury and/or anoxic changes in the brain;
short interval.
skull fracture (if impact occurred); and retinal hemorrhages.
While bathing the infant the next morning, the mother noticed a
Constant features are subdural and retinal hemorrhages. Various
deep purple bruise on her arm. Another bruise appeared about 2 cm fractures including those of the long bones and ribs are often used to
from the first one. No investigations were done to establish the support an impression of child abuse, but it should not be forgotten
cause of these bruises. that Barlow’s disease can resemble “battered baby.”
7
Following this episode the infant was reasonably well, and at As far as we are aware, no one has measured the blood levels of
age 7 weeks weighed 4.25 kg. She was given DTaP, Hib, and vitamin C or histamine in cases of suspected SBS. The possible
meningitis C vaccines at 8 weeks. From then on, she refused her existence of vitamin C deficiency is therefore hypothesized from
regular feedings and started vomiting, and was therefore admitted clinical, radiological, and other laboratory findings. There are
to the hospital six days after the vaccinations. several features, common to both cases, that predispose to or are
After discharge from hospital, while being bottle-fed by the consistent with a diagnosis of vitamin C deficiency:
father 11 days after being vaccinated, she “suddenly collapsed, 1. The mothers had documented nutritional problems and were
stopped breathing, and went floppy.” The physician on emergency unwell during their pregnancies.
call found the baby “very blue initially” and said she may have been 2. The mothers smoked during their pregnancies, thereby
“hypoxic for 6-8 minutes.” CPR was attempted and the infant was lowering their own and their infants’vitamin C levels.
admitted to the hospital, where she was intubated and resuscitated, 3. Both infants were being formula fed at the time of their
but died shortly afterward. illnesses, and the mothers were not advised to give supplemental
Radiological findings included a subdural hemorrhage, 12 vitamin C.
“fractures” involving all four limbs, and seven rib “fractures” of 4. Both parents reported early evidence consistent with
varying ages. These findings were confirmed at post-mortem Barlow’s disease: spontaneous bruising in one infant and delayed
examination. wound healing in the other.
18 Journal of American Physicians and Surgeons Volume 11 Number 1 Spring 2006

3. 5. Both infants had deficiencies in essential and nonessential cases. Poor nutrition and possible vaccine-induced vitamin C
amino acids necessary for the production of normal collagen, which deficiency associated with temporary brittle bone disease may
is essential to prevent scurvy. represent alternative explanations. Infantile scurvy, while
6. Both infants had evidence of liver dysfunction. uncommon in affluent countries, should nevertheless be routinely
7. Unexplained “fractures” were recorded in both children. excluded before a diagnosis of SBS is made.
In addition to the low amino acid levels, the second infant had
additional evidence of malnutrition in that the serum albumin, Michael D. Innis, MBBS, DTM&H, FRCPA, FRCPath, is honorary
calcium, and hemoglobin levels were all low. consultant hematologist, Princess Alexandra Hospital, Brisbane,
Animal experiments have demonstrated that administration of Queensland, Australia. Contact: 1 White-Dove Court, Wurtulla,
vitamin C can counter some of the ill effects of nicotine in Queensland, Australia 4575. Phone +61 (0)7.5493.2826. Fax +61
newborns.11 This suggests that mothers who smoke may (0)7.5493. 2826. Contact: micinnis@ozemail.com.au.
compromise vitamin C levels in their children.
One essential function of vitamin C is maintenance of normal Acknowledgements: I wish to thank the parents of the children reported
connective tissue by the hydroxylation of proline and lysine in here for sending me the records of the children and allowing me to report the
results of the investigation.
procollagen, using the enzyme prolyl hydroxylase with vitamin C
as a cofactor.1 2While vitamin C has numerous other functions, this
Potential Conflict of Interest: Dr. Innis has have been paid consulting fees
one maintains the integrity of the blood vessels, bones, and dentine,
in three cases of alleged child abuse, but in none of them was the question
which is compromised in scurvy, leading to the manifestations that
of vaccination raised. He has given his opinion pro bono in several others.
might be mistaken for SBS. A lack of normal collagen causes
capillary walls to break down, and hemorrhaging may occur from
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11
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12
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14
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15
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Journal of American Physicians and Surgeons Volume 11 Number 1 Spring 2006 19